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feb 2012_d11 virginia high school league inc 1642 state farm blvd charlottesville va 22911 separate signed form is required for each school year for school year print clearly routing 1 2 3 page 1 of 4 athletic participation/parental consent/physical examination form may 1 of the current year through june 30 of the succeeding year male female part i athletic participation to be filled in and signed by the student name last first middle initial student i.d home address city/zip code home address of parents city/zip code date of birth this is my semester in semester i attended represent my present high school in athletics place of birth high school and my semester since first entering the ninth grade last school and passed credit subjects and i am taking credit subjects this semester i have read the condensed individual eligibility rules of the virginia high school league that appear below and believe i am eligible to individual eligibility rules to be eligible to represent your school in any vhsl interscholastic athletic contest you-· must be a regular bona fide student in good standing of the school you represent · must be enrolled in the last four years of high school eighth-grade students may be eligible for junior varsity · must have enrolled not later than the fifteenth day of the current semester · for the first semester must be currently enrolled in not fewer than five subjects or their equivalent offered for credit and which may be used for graduation and have passed five subjects or their equivalent offered for credit and which may be used for graduation the immediately preceding year or the immediately preceding semester for schools that certify credits on a semester basis check with your principal for equivalent requirements may not repeat courses for eligibility purposes for which credit has been previously awarded · for the second semester must be currently enrolled in not fewer than five subjects or their equivalent offered for credit and which may be used for graduation and have passed five subjects or their equivalent offered for credit and which may be used for graduation the immediately preceding semester check with your principal for equivalent requirements · must sit out all vhsl competition for 365 consecutive calendar days following a school transfer unless the transfer corresponded with a family move check with your principal for exceptions · must not have reached your nineteenth birthday on or before the first day of august of the current school year must not after entering the ninth grade for the first time have been enrolled in or been eligible for enrollment in high school more than eight consecutive semesters · must have submitted to your principal before any kind of participation including tryouts or practice as a member of any school athletic or cheerleading team an athletic participation/parental consent/physical examination form completely filled in and properly signed attesting that you have been examined during this school year and found to be physically fit for athletic competition and that your parents consent to your participation · must not be in violation of vhsl amateur awards all star or college team rules check with your principal for clarification in regard to cheerleading eligibility to participate in interscholastic athletics is a privilege you earn by meeting not only the above-listed minimum standards but also all other standards set by your league district and school if you have any question regarding your eligibility or are in doubt about the effect an activity might have on your eligibility check with your principal for interpretations and exceptions provided under league rules meeting the intent and spirit of league standards will prevent you your team school and community from being penalized additionally i give my consent and approval for my picture and name to be printed in any high school or vhsl athletic program publication or video local school divisions and vhsl districts may require additional standards to those listed above student signature date providing false information will result in ineligibility for one year.

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feb 2012_d11 part ii medical history explain yes answers below general medical history 1 has a doctor ever denied or restricted your participation in sports for any reason 2 do you currently have an ongoing medical condition if so asthma anemia diabetes please identify infections other 3 have you ever spent the night in the hospital 4 have you ever had surgery yes no page 2 of 4 this form must be completed and signed prior to the physical examination for review by examining practitioner explain yes answers below with number of the question circle questions you don t know the answers to medical questions cont 29 do you have groin pain or a painful bulge or hernia in the groin area 30 have you had mononucleosis mono within the last month 31 do you have any rashes pressure sores or other skin problems 32 have you ever had a herpes or mrsa skin infection 33 are you currently taking any medication on daily basis 34 have you ever had a head injury or concussion if so date of last injury 35 have you ever had a numbness tingling or weakness in your arms or legs after being hit or falling 36 do you have headaches with exercise 37 have you ever been unable to move your arms or legs after being hit or falling 38 when exercising in heat do you have severe muscle cramps or become ill 39 has a doctor told you that you or someone in your family has sickle cell trait or sickle cell disease 40 have you had any other blood disorders yes no 41 have you had any problems with your eyes or vision 42 do you wear glasses or contact lenses 43 do you wear protective eyewear such as goggles or a face shield 44 do you worry about your weight 45 are you trying to or has any professional recommended that you try to gain or lose weight 46 do you limit or carefully control what you eat yes no 47 do you have any concerns that you would like to discuss with a doctor 48 when is the date of your last tdap or td tetanus immunization circle type date females only 49 have you ever had a menstrual period 50 age when you had your first menstrual period 51 how many periods have you had in the last 12 months yes no heart health questions about you 5 have you ever passed out or nearly passed out during or after exercise 6 have you ever had discomfort pain or pressure in your chest during exercise 7 does your heart race or skip beats during exercise 8 has a doctor ever told you that you have check all that apply high blood pressure a heart murmur high cholesterol a heart infection kawasaki disease other 9 has a doctor ever ordered a test for your heart for ex ecg/ekg echocardiogram 10 do you get lightheaded or feel more short of breath than expected during exercise 11 have you ever had an unexplained seizure heart health questions about your family 12 has any family member or relative died of heart problems or had an unexpected sudden death before age 50 including drowning unexplained car accident or sudden infant death syndrome yes no 13 does anyone in your family have a heart problem 14 does anyone in your family have a pacemaker or implanted defibrillator 15 does anyone in your family have marfan syndrome cardiomyopathy or long q-t 16 has anyone in your family had unexplained fainting unexplained seizures or near drowning bone and joint questions 17 have you ever had an injury like a sprain muscle or ligament tear or tendonitis that caused you to miss a practice or game 18 have you had any broken or fractured bones or dislocated joints 19 have you had a bone or joint injury that required x-rays mri ct surgery injections rehabilitation physical therapy a brace a cast or crutches 20 have you ever had an x-ray of your neck for atlanto-axial instability or have you ever been told that you have that disorder or any neck/spine problem 21 have you ever had a stress fracture of the bone 22 do you regularly use a brace or assistive device 23 do you currently have a bone muscle or joint injury that bothers you 24 do any of your joints become painful swollen feel warm or look red 25 do you have a history of juvenile arthritis or connective tissue disease explain yes answers below » » » » yes no » medical questions 26 do you cough wheeze or have difficulty breathing during or after exercise 27 do you have asthma or use asthma medicine inhaler nebulizer 28 were you born without or are you missing a kidney an eye a testicle spleen or any other organ list medications and nutritional supplements you are currently taking here parent/guardian signature date athlete s signature

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feb 2012_d11 part iii ­ physical examination page 3 of 4 th physical examination is required each school year after may 1 of the preceding school year and is good through june 30 of the current school year name date of birth school examination height bp medical appearance eyes/ears/nose/throat lymph nodes heart pulses lungs abdomen genitourinary males only skin neurologic weight pulse normal male female vision r 20 l 20 corrected yes no abnormal findings musculoskeletal neck back shoulder/arm elbow/forearm wrist/hand/fingers hip/thigh knee leg/ankle foot/toes functional normal abnormal findings medical practitioner to school staff please indicate any instructions or recommendations here emergency medications required on-site inhaler epinephrine glucagon other comments i have reviewed the data above reviewed his/her medical history form and make the following recommendations for his/her participation in athletics cleared without restrictions cleared with following notation cleared after documented further evaluation or treatment for cleared for limited participation check and explain reason for all that apply limited until date when appropriate not cleared for specific sports until date reasons not cleared for participation reason i have examined the above-named student and completed the preparticipation physical evaluation physician signature md do lnp pa date circle one examiner s name and degree print phone number address city state zip only signatures of doctor of medicine doctor of osteopathic medicine nurse practitioner or physician s assistant licensed to practice in the united states will be accepted

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feb 2012_d11 page 4 of 4 part iv acknowledgement of risk and insurance statement to be completed and signed by parent/guardian i give permission for name of child/ward to participate in any of the following sports that are not crossed out baseball basketball cheerleading cross country field hockey football golf gymnastics lacrosse soccer softball swimming/diving tennis track volleyball wrestling other identify sports i have reviewed the individual eligibility rules and i am aware that with the participation in sports comes the risk of injury to my child/ward i understand that the degree of danger and the seriousness of the risk varies significantly from one sport to another with contact sports carrying the higher risk i have had an opportunity to understand the risk inherent in sports through meetings written handouts or some other means he/she has student medical/accident insurance available through the school yes no has athletic participation insurance coverage through the school yes no is insured by our family policy with name of medical insurance company policy number name of policy holder i am aware that participating in sports will involve travel with the team i acknowledge and accept the risks inherent in the sport and with the travel involved and with this knowledge in mind grant permission for my child/ward to participate in the sport and travel with the team by this signature i hereby consent to allow the physicians and other health care providers selected by myself or the school to perform a pre-participation examination on my child and to provide treatment for any injury or condition resulting from participating in athletics/activities for his/her school during the school year covered by this form i further consent to allow said physicians or heath care providers to share appropriate information concerning my child that is relevant to participation in athletics and activities with coaches and other school personnel as deemed necessary additionally i give my consent and approval for the above named student s picture and name to be printed in any high school or vhsl athletic program publication or video part v emergency permission form to be completed and signed by parent/guardian student s name high school grade age city please list any significant health problems that might be significant to a physician evaluating your child in case of an emergency please list any allergies to medications etc is the student currently prescribed an inhaler or epi-pen list the emergency medication is student presently taking any other medication if so what type does student wear contact lenses date of last tetanus shot emergency authorization in the event i cannot be reached in an emergency i hereby give permission to physicians selected by the coaches and staff of high school to hospitalize secure proper treatment for and to order injection and/or anesthesia and/or surgery for the person named above daytime phone number where to reach you in emergency evening time phone number where to reach you in emergency cell phone signature of parent or guardian date relationship to student emergency permission form may be reproduced to travel with respective teams and is acceptable for emergency treatment if needed i certify all the above information is correct parent/guardian signature

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